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©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
Dabigatran, rivaroxaban, and apixaban are superior to warfarin in Asian patients with non-valvular atrial fibrillation: An updated meta-analysis
Wei-Jia Li, Paraschos Archontakis-Barakakis, Leonidas Palaiodimos, Dimitrios Kalaitzoglou, Lazaros Tzelves, Apostolos Manolopoulos, Yu-Chiang Wang, Stefanos Giannopoulos, Robert Faillace, Damianos G Kokkinidis
Wei-Jia Li, Paraschos Archontakis-Barakakis, Leonidas Palaiodimos, Yu-Chiang Wang, Robert Faillace, Damianos G Kokkinidis, Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, United States
Dimitrios Kalaitzoglou, Department of Surgery, 424 General Army Hospital of Thessaloniki, Thessaloniki 56429, Greece
Lazaros Tzelves, Department of Urology, Sismanogleio Hospital, Athens 15126, Greece
Apostolos Manolopoulos, Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
Stefanos Giannopoulos, Division of Cardiology, Rocky Mountain Regional VA Medical Center, Denver, CO 80045, United States
Author contributions: All listed authors have: (1) Substantial contributions to the conception and design or the acquisition, analysis, or interpretation of the data; (2) Substantial contributions to the drafting of the articles or critical revision for important intellectual content; (3) Final approval of the version to be published; and (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved.
Conflict-of-interest statement: All the authors declare no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
http://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Damianos G Kokkinidis, MD, MSc, Academic Fellow, Doctor, Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY 10461, United States. damiankokki@gmail.com
Received: December 8, 2020
Peer-review started: December 8, 2020
First decision: February 15, 2021
Revised: February 21, 2021
Accepted: April 13, 2021
Article in press: April 13, 2021
Published online: April 26, 2021
BACKGROUND
Most of the randomized clinical trials that led to the wide use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) originated from western countries.
AIM
To systematically review and quantitatively synthesize the real-world data regarding the efficacy and safety of dabigatran, rivaroxaban, and apixaban compared to warfarin for stroke prevention in Asian patients with non-valvular AF.
METHODS
Medline, Cochrane, and ClinicalTrial.gov databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. The primary outcome was ischemic stroke. The secondary outcomes were all-cause mortality, major bleeding, intracranial hemorrhage, and gastrointestinal bleeding.
RESULTS
Twelve studies from East Asia or Southeast Asia and 441450 patients were included. Dabigatran, rivaroxaban, and apixaban were associated with a significant reduction in the incidence of ischemic stroke [hazard ratio (HR) = 0.78, 95% confidence interval (CI): 0.65-0.94; HR = 0.79, 95%CI: 0.74-0.85, HR = 0.70, 95%CI: 0.62-0.78; respectively], all-cause mortality (HR = 0.68, 95%CI: 0.56-0.83; HR = 0.66, 95%CI: 0.52-0.84; HR = 0.66, 95%CI: 0.49-0.90; respectively), and major bleeding (HR = 0.61, 95%CI: 0.54-0.69; HR = 0.70, 95%CI: 0.54-0.90; HR = 0.58, 95%CI: 0.43-0.78; respectively) compared to warfarin.
CONCLUSION
Dabigatran, rivaroxaban, and apixaban appear to be superior to warfarin in both efficacy and safety in Asians with non-valvular AF.
Core Tip: Dabigatran, rivaroxaban, apixaban have better efficacy (reduction in ischemic stroke and all-cause mortality) and are safer (reduction in major bleeding) than warfarin. Dabigatran is associated with a lower rate of intracranial hemorrhage than warfarin, while rivaroxaban and apixaban appear to have a trend towards reduced intracranial hemorrhage, without statistical significance. Dabigatran, rivaroxaban, and apixaban are associated with a lower rate of gastrointestinal bleeding.
